Kim Ann H, Kendrick Daniel E, Moorehead Pamela A, Nagavalli Anil, Miller Claire P, Liu Nathaniel T, Wang John C, Kashyap Vikram S
Division of Vascular Surgery, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio.
J Vasc Surg. 2016 Jul;64(1):251-8. doi: 10.1016/j.jvs.2016.01.050. Epub 2016 Mar 19.
The use of simulators for endovascular aneurysm repair (EVAR) is not widespread. We examined whether simulation could improve procedural variables, including operative time and optimizing proximal seal. For the latter, we compared suprarenal vs infrarenal fixation endografts, right femoral vs left femoral main body access, and increasing angulation of the proximal aortic neck.
Computed tomography angiography was obtained from 18 patients who underwent EVAR at a single institution. Patient cases were uploaded to the ANGIO Mentor endovascular simulator (Simbionix, Cleveland, Ohio) allowing for three-dimensional reconstruction and adapted for simulation with suprarenal fixation (Endurant II; Medtronic Inc, Minneapolis, Minn) and infrarenal fixation (C3; W. L. Gore & Associates Inc, Newark, Del) deployment systems. Three EVAR novices and three experienced surgeons performed 18 cases from each side with each device in randomized order (n = 72 simulations/participant). The cases were stratified into three groups according to the degree of infrarenal angulation: 0° to 20°, 21° to 40°, and 41° to 66°. Statistical analysis used paired t-test and one-way analysis of variance.
Mean fluoroscopy time for participants decreased by 48.6% (P < .0001), and total procedure time decreased by 33.8% (P < .0001) when initial cases were compared with final cases. When stent deployment accuracy was evaluated across all cases, seal zone coverage in highly angulated aortic necks was significantly decreased. The infrarenal device resulted in mean aortic neck zone coverage of 91.9%, 89.4%, and 75.4% (P < .0001 by one-way analysis of variance), whereas the suprarenal device yielded 92.9%, 88.7%, and 71.5% (P < .0001) for the 0° to 20°, 21° to 40°, and 41° to 66° cases, respectively. Suprarenal fixation did not increase seal zone coverage. The side of femoral access for the main body did not influence proximal seal zone coverage regardless of infrarenal angulation.
Simulation of EVAR leads to decreased fluoroscopy times for novice and experienced operators. Side of femoral access did not affect precision of proximal endograft landing. The angulated aortic neck leads to decreased proximal seal zone coverage regardless of infrarenal or suprarenal fixation devices.
血管内动脉瘤修复术（EVAR）模拟器的使用并不广泛。我们研究了模拟是否能改善手术变量，包括手术时间和优化近端密封。对于后者，我们比较了肾上固定与肾下固定的内支架移植物、右股动脉与左股动脉主体入路，以及增加近端主动脉颈的成角。
从在单一机构接受EVAR的18例患者中获取计算机断层扫描血管造影。将患者病例上传至ANGIO Mentor血管内模拟器（Simbionix，俄亥俄州克利夫兰），以进行三维重建，并适配用于肾上固定（Endurant II；美敦力公司，明尼阿波利斯，明尼苏达州）和肾下固定（C3；W.L.戈尔公司，纽瓦克，特拉华州）展开系统的模拟。三名EVAR新手和三名经验丰富的外科医生以随机顺序使用每种设备从两侧各进行18例手术（每位参与者72次模拟）。根据肾下成角程度将病例分为三组：0°至20°、21°至40°和41°至66°。采用配对t检验和单因素方差分析进行统计分析。
与初始病例相比，参与者的平均透视时间减少了48.6%（P <.0001），总手术时间减少了33.8%（P <.0001）。在评估所有病例的支架展开准确性时，高度成角的主动脉颈处的密封区覆盖率显著降低。肾下装置导致主动脉颈区域平均覆盖率分别为91.9%、89.4%和75.4%（单因素方差分析P <.0001），而肾上装置在0°至20°、21°至40°和41°至66°的病例中分别为92.9%、88.7%和71.5%（P <.0001）。肾上固定并未增加密封区覆盖率。无论肾下成角情况如何，主体的股动脉入路侧对近端密封区覆盖率均无影响。
EVAR模拟可减少新手和经验丰富操作者的透视时间。股动脉入路侧不影响近端内支架着陆的精度。无论使用肾下还是肾上固定装置，成角的主动脉颈都会导致近端密封区覆盖率降低。
